Claudication due to adventitial cystic degeneration: A differential diagnosis of peripheral artery disease

Background Cystic adventitial disease (CAD) is an important and rare non-atherosclerotic cause of intermittent claudication and critical limb ischemia. Since the first case of CAD involving the external iliac artery was described by Atkins and Key in 1947, approximately 300 additional cases have been reported. Objectives The aim of this article is to report a rare vascular disorder, predominantly seen in young healthy men with minimal cardiovascular risk factors. Methods We report a rare case of cystic adventitial disease of a young policeman. To confirm the diagnosis, an ultrasonography and a conventional angiography were performed. The therapeutic approach was surgical first. Results The procedure was successful without any complication, and the patient was discharged to home 4 days after procedure. Conclusion While CAD is rare, the diagnosis should be suspected in a young patient who presents with arterial insufficiency and no risk factors for atherosclerosis. Catheter angiography is the investigation of choice in the absence of multislice CT and good MRA. It seems that the treatment that assures the best long-term results is reconstructive arterial bypass surgery.

The possibility of using autologous adipose tissue for the stage shin wound closing

Extensive soft tissue defects can be complicated by systemic diseases (trophic ulcers in diabetes mellitus, chronic arterial insufficiency) or the result of trauma (domestic, military, operating, etc.). The current increase in the incidence of this pathology is due to the spread of cardiovascular diseases and diabetes mellitus. Closing an infected long-term non-healing wound, such as a tendon or bone, is one of the most difficult tasks of reconstructive surgery. For example, the use of classical methods of closing wound conditions is difficult to a degree due to the patient's polymorbid background. The clinical case presented in the article shows the possibility of closing deep shin wound with a complex relief by the transplantation of autologous adipose tissue, a patient with severe concomitant pathology.

Vascular pythiosis caused by Pythium aphanidermatum: the first case report in Asia

Background Pythium, soil-borne plant pathogens, are in the class Oomycetes. They are not true fungi, but are related to diatom and algae. There are two human pathogens including P. insidiosum and P. aphanidermatum. To date, only one case of pythiosis caused by P. aphanidermatum has been reported. We present herein the first case of P. aphanidermatum vascular pythiosis in Asia. Case presentation A 47-year-old Thai woman, living in North Thailand, with ß thalassemia/hemoglobin E presented with acute recurrent arterial insufficiency of both legs. Emergent embolectomy with clot removal was performed. The pathology of the clot exhibited noncaseous granulomatous inflammation with many fungal hyphal elements. PCR identified P. aphanidermatum with 100% identity. Final diagnosis is vascular pythiosis. Unfortunately, the patient eventually expired after treatment with itraconazole, terbinafine, azithromycin, and doxycycline. Conclusions To date, only one case of pythiosis caused by P. aphanidermatum has been reported. We present herein the first case of P. aphanidermatum vascular pythiosis in Asia.

Lower limb amputation following venous cannulation for VA-ECMO: a case report

Lower limb amputation following arterial cannulation for VA-ECMO has been described in the literature. Limb ischemia however following venous cannulation is very rare and not quite understood. We present a case of limb ischemia following venous cannulation. A combination of venous congestion, compartment syndrome and subsequent arterial insufficiency is the proposed pathophysiology. Shock and use of vasopressors are compounding factors. Limb ischemia can be transient and reversible if diagnosed immediately and treated by early removal of the cannula. Our patient was unstable and ECMO dependent, and removal of the cannula was not an option. This resulted in limb loss and eventual above knee amputation. Use of the smallest appropriate venous cannula and early fasciotomy, in addition to hemodynamic optimization are measures that could help in preventing major amputation.

TP5.2.11 Intervention for mesenteric arterial insufficiency in octogenarians

Introduction Mesenteric ischaemia is associated with significant morbidity and mortality. The poor prognosis associated with mesenteric ischaemia may prejudice decision-making, particularly for an older patient group. We have explored outcomes following intervention for mesenteric ischaemia in patients aged over 80-years old. Methods This was a retrospective analysis of a database of intervention for mesenteric ischaemia from 2010 to 2020 from a regional vascular unit covering two Health Boards in Scotland. Patients aged 80-years and over were identified and patterns of intervention and outcome described. Results There were 23 procedures performed – there were 17 patients aged 80-years or over. There were 8 patients with acute presentations, 6 had isolated superior mesenteric artery occlusion and thromboembolectomy was the most common procedure (n = 4). Laparotomy was performed in all cases and bowel resection required in 3. At 30-days 4 patients had died, but patients who survived the index admission were still alive at 1-year and symptom free. Elective was performed on 9 patients. An endovascular approach was favoured (n = 7) with the superior mesenteric artery the preferred target. At 30-days 2 had died, but at 1-year there had only been 1 further death. Three patients experienced recurrent symptoms. The remaining patients were symptom free. Conclusion It is appropriate to consider mesenteric intervention for older patients with both acute and chronic mesenteric ischaemia. Meaningful survival can be achieved with good relief of symptoms and return to meaningful quality of life.

SP3.1.17 Assessment of the utility of CT to predict the requirement for resection at laparotomy in patients presenting with acute mesenteric arterial insufficiency

Introduction Mesenteric ischaemia as a consequence of arterial atherosclerosis is associated with significant morbidity and mortality. Practice has been influenced by the rise in cross-sectional imaging. In Glasgow a policy of laparotomy for patients presenting with acute mesenteric ischaemia at the time of mesenteric revascularisation has been adopted. We have sought to define whether CT can predict visceral necrosis and a requirement for tissue resection at the primary revascularisation. Methods This was a retrospective review of interventions performed for mesenteric ischaemia. Radiological variables described in the context of mesenteric ischaemia were defined. The primary CT report was reviewed to define whether these features were recorded and whether a diagnosis of mesenteric ischaemia was suggested. Imaging was then retrospectively reviewed with reference to the dataset by a radiologist. The radiologist was asked to offer a subjective opinion as to whether there was mesenteric infarction. These data were compared with laparotomy findings. Results There were 129 interventions performed for mesenteric ischaemia over the study period and 147 laparotomies. There was no specific radiological variable that was consistently reported in the primary or secondary CT review. However when bowel wall thinning, hypoattenuation or portal venous gas reported (independently) they seemed to be specific as in each case there was mesenteric infarction at laparotomy. Conclusion Even with retrospective radiological assessment there is no reliable feature that will predict mesenteric infarction and a requirement for tissue resection. As such a policy of laparotomy in patients who considered physiologically well enough would appear to be justified.

Results of infrainguinal reconstructions with distal anastomosis below the knee joint fissure in patients with critical ischemia when using various prosthetic materials

Aim. To cоmpare the results оf infra-spinal reconstructions of the lower extremities with the formatiоn of a distal anastomоsis below the knee joint fissure with the use of a bioprosthesis and autovein in critical limb ischemia (CLI).Methods. The hospital results of revascularization were retrospectively analyzed in 53 patients with CLI who underwent primary prosthetics of the femoral-popliteal segment with the fоrmation of a distal anastomоsis belоw the knee joint gap. All patients, depending on the prоsthetic material used, were divided into two groups: 1) autovein was used as a prosthesis (39.6%, n = 21)) and 2) a bioprosthesis was used (“KemAngioprosthesis” closed joint-stock company “NeoCor” Kemerovo, Russia) (60.4%, n = 32).Results. In the early postoperative period, thrombosis developed in group 1 in 7 cases (33.3%): in 5 patients – on the first day after the surgery; 2 out of 5 patients were with chronic arterial insufficiency (CAI) of the fourth degree, 1 was with acute arterial insufficiency of the first degree, and 2 patients with the third degree of CAI. In group 2, there were 6 prosthetic thrombosis (18.7%), 4 cases of which developed thrombosis on the first day, 3 patients with CAI of the fourth degree and 1 case with acute arterial insufficiency of the second degree.Conclusion. The application of infra-lingual reconstructions using bioprostheses is quite effective and safe in patients with CLI, in particular with purulent-necrotic trophic processes when a suitable autovein to be used as a prosthetic material is absent.

Risk factors for a delayed course of reparative processes after destructive intervention on the integumentary tissues of the foot

В статье обобщены сведения о заболеваниях и состояниях, оказывающих влияние на процессы нормального заживления после деструктивных вмешательств на покровных тканях стопы, представлены современные данные литературы, посвященные этим вопросам. Неадекватная оценка состояния пациента перед проведением планового деструктивного вмешательства на нижних конечностях может привести к формированию длительно незаживающего раневого дефекта и нарушению функции конечности. Проведение деструктивного вмешательства требует настороженности в отношении ряда заболеваний и состояний, влияющих на процессы нормального заживления, таких как сахарный диабет, метаболический синдром, иммунодефицит. Особое внимание в статье уделено оценке состоятельности кровотока нижних конечностей в связи с тем, что хроническая артериальная недостаточность является одной из наиболее значимых причин замедленного течения репаративных процессов в области стоп. Представлено собственное клиническое наблюдение, иллюстрирующее отсутствие нормальной регенерации в условиях гипергликемии и хронической артериальной недостаточности нижних конечностей. The article summarizes information about diseases and conditions that affect the processes of normal healing after destructive interventions on the integumentary tissues of the foot, presents modern literature data on these issues. An inadequate assessment of the patient's condition before a planned destructive intervention on the lower extremities can lead to a long-term non-healing wounds and dysfunction of the extremity. A destructive intervention requires attention to a number of diseases and conditions that affect normal healing processes, such as diabetes mellitus, metabolic syndrome, and immunodeficiency. Particular attention is paid to the assessment of the consistency of the blood flow of the lower extremities because chronic arterial insufficiency is one of the most significant reasons for the slow reparative processes in the foot area. The authors present their own clinical observation that illustrates the absence of normal regeneration in conditions of hyperglycemia and chronic arterial disease of the lower limbs. Keywords: destruction, destructive interventions, atherosclerosis, wound healing, regeneration, chronic arterial insufficiency, lower limbs, delayed healing.

X-ray endovascular methods for the treatment of veno-occlusive erectile dysfunction

The results of surgical treatment of 59 patients with veno-occlusive erectile dysfunction and follow-up of 8 years are presented. The age of patients is 18-48 years old (average age is 29.3 ± 7.6). Five of them had hemodynamic and clinical signs of arteriovenous erectile dysfunction in the stage of subcompensation, 16 patients underwent simultaneous treatment in the form of sclerotherapy of testicular veins in connection with the secretory type of male infertility, 5 underwent simultaneous surgical treatment to eliminate veno-occlusive and arterial insufficiency of the cavernous bodies of the penis by stenting of the internal iliac or pudendal arteries, 2 patients underwent delayed stenting of the iliac veins due to May-Turner syndrome, the remaining patients underwent surgical treatment aimed at eliminating venous erectile dysfunction. The diagnosis was established on the basis of a clinical and urological examination, including physical examination and questioning according to the IIEF-5 (International Index of Erectile Function), ultrasound Doppler examination of the cavernous bodies of the penis with intracavernous pharmacotest, dynamic computer pharmacocavernosography with 3D reconstruction, with veno-occlusive arteries with suspected arteries, or computer tomography arterial insufficiency of the cavernous bodies of the penis. All types of endovascular and hybrid operations on the venous collectors of the penis were analyzed. Priority surgical techniques for the treatment of pathological venous drainage have been identified, which are 75 % effective in the long-term postoperative period. Based on the presented experience of the authors and analysis of foreign literature, the expediency of revising the European and Russian recommendations for venous surgery of the penis towards the priority use at the first stage of minimally invasive X-ray surgical treatment in a category of young patients has been proved.